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Hoe richten we Nederland handig in? Om die vraag te beantwoorden, keken we eeuwenlang eerst naar het landschap. Je kunt bijvoorbeeld niet overal huizen bouwen, want op veel plekken is de grond te nat, te laag of te zacht. Voedsel verbouwen kan alleen waar de bodem genoeg voedingsstoffen bevat en water in de buurt is. Ook in Rivierenland voegden inwoners zich naar de eigenschappen van de omgeving. Oude dorpen en steden liggen vaak langs de rivier, op de hogere delen. Want daar is zoetwater én houd je droge voeten. Het is ook geen toeval dat regio Rivierenland bekendstaat om haar fruitteelt. Grote delen van het rivierengebied hebben een zeer vruchtbare bodem, waardoor fruitbomen er goed groeien. Het landschap was dus leidend bij ruimtelijke keuzes. Maar de afgelopen decennia zijn we dat principe vergeten. Dankzij bemesting, en later kunstmest, konden we ineens voedsel verbouwen op arme grond. Door afwateringssystemen en hoge dijken zijn we huizen gaan bouwen in lage, natte gebieden. We dachten het water onder controle te hebben. Mooi, zou je zeggen, want zo kunnen we het land precies inrichten zoals we willen. Maar helaas heeft deze gedachte ook veel nadelen. Tegenwoordig kom je allerlei soorten landgebruik tegen, op plekken die daar vanuit de bodem en het watersysteem niet logisch zijn. Van nieuwbouwwijken in de uiterwaarden, tot grote boerenbedrijven op arme zandgrond of in diepe polders. Nu het klimaat verandert, moeten we met z’n allen steeds harder werken om te voorkomen dat we natte voeten krijgen – of erger. Het is dus tijd om op zoek te gaan naar een nieuwe balans.

Objective: Magnetic resonance imaging (MRI) of small joints sensitively detects inflammation. This inflammation, and tenosynovitis in particular, has been shown to predict rheumatoid arthritis (RA) development in arthralgia patients. These data have predominantly been acquired on 1.0–1.5 T MRI. However, 3.0 T is now commonly used in practice. Evidence on the comparability of these field strengths is scarce and has never included subtle inflammation in arthralgia patients or tenosynovitis. Therefore, we assessed the comparability of 1.5 T and 3.0 T in detecting subclinical inflammation in arthralgia patients.Method: A total of 2968 locations (joints, bones, tendon sheaths) in the hands and forefeet of 28 patients with small-joint arthralgia, at risk for RA, were imaged on both 1.5 and 3.0 T MRI. Two blinded readers independently scored erosions, osteitis, synovitis, and tenosynovitis, in line with the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS). Features were summed into inflammation (osteitis, synovitis, tenosynovitis) and RAMRIS (inflammation and erosions). Agreement was assessed with intraclass correlation coefficients (ICCs) for continuous scores and after dichotomization into presence or absence of inflammation, on patient and location levels.Results: Interreader ICCs were excellent (> 0.90). Comparing 1.5 and 3.0 T revealed an ICC of 0.90 for inflammation and RAMRIS. ICCs for individual inflammation features were: tenosynovitis 0.87 (95% confidence interval 0.74–0.94), synovitis 0.65 (0.24–0.84), and osteitis 0.96 (0.91–0.98). Agreement was 83% for inflammation and 89% for RAMRIS. Analyses on the location level showed similar results.Conclusion: Agreement on subclinical inflammation between 1.5 T and 3.0 T was excellent. Although synovitis scores were slightly different, synovitis often occurs simultaneously with other inflammatory signs, suggesting that scientific results on the predictive value of MRI-detected inflammation for RA, obt

Objective: To investigate if knee osteoarthritis (OA) is associated with lower physical activity in the general middle-aged Dutch population, and if physical activity is associated with patient-reported outcomes in knee OA. Design: Clinical knee OA was defined in the Netherlands Epidemiology of Obesity population using the ACR criteria, and structural knee OA on MRI. We assessed knee pain and function with the Knee Injury and Osteoarthritis Score (KOOS), health-related quality of life (HRQoL) with the Short Form-36, and physical activity (in Metabolic Equivalent of Task (MET) hours) with the Short Questionnaire to Assess Health-enhancing physical activity. We analysed the associations of knee OA with physical activity, and of physical activity with knee pain, function, and HRQoL in knee OA with linear regression adjusted for potential confounders. Results: Clinical knee OA was present in 14% of 6,212 participants, (mean age 56 years, mean BMI 27 kg/m2, 55% women, 24% having any comorbidity) and structural knee OA in 12%. Clinical knee OA was associated with 9.60 (95% CI 3.70; 15.50) MET hours per week more physical activity, vs no clinical knee OA. Structural knee OA was associated with 3.97 (−7.82; 15.76) MET hours per week more physical activity, vs no structural knee OA. In clinical knee OA, physical activity was not associated with knee pain, function or HRQoL. Conclusions: Knee OA was not associated with lower physical activity, and in knee OA physical activity was not associated with patient-reported outcomes. Future research should indicate the optimal treatment advice regarding physical activity for individual knee OA patients.

Background: The forefoot is a preferential location for joint and tendon sheath inflammation in rheumatoid arthritis (RA). It also contains bursae, of which the intermetatarsal bursae have a synovial lining. Some small imaging studies suggested that intermetatarsal bursitis (IMB) and submetatarsal bursitis (SMB) are involved in RA, but their association has not been thoroughly explored. Healthy control studies suggested that lesion size might be relevant. We studied the relation between IMB and SMB in early RA, compared to other arthritides and healthy controls, and the relevance of lesion sizes. Methods: Six hundred and thirty-four participants were studied: 157 consecutive patients presenting with early RA, 284 other arthritides, and 193 healthy controls. All underwent unilateral contrast-enhanced MRI of the forefoot at presentation. Two readers independently scored IMB and SMB and measured transverse and dorsoplantar diameters, blinded to clinical data. Subsequently, consensus was reached. Intra-reader ICC was 0.89. Logistic regression models were used, and test characteristics were calculated. Results: IMB and SMB associated with RA independent of each other (P < 0.001) and independent of age, gender, BMI, RA-MRI inflammation, and anti-CCP-antibodies (P = 0.041). Sensitivity for RA of IMB was 69%, and for SMB 25%. Specificity for IMB was 70% compared to other arthritides, and 84% compared to healthy controls. For SMB, this was 94% and 97% respectively. Regarding lesion size, the groups had considerable overlap: no cut-off size for RA could be distinguished with high sensitivity and specificity. Conclusion: Intermetatarsal and submetatarsal bursitis associated with early rheumatoid arthritis, contributing to the emerging evidence that inflammation of juxta-articular soft tissues is an early feature of RA.

Background: It remains unclear to what extent patients with traumatic knee complaints aged 18–45 years seen in general practice experience difficulties with return to sports. Objectives: This study aims to determine the proportion of patients with a knee trauma that return to sports at six weeks and three months follow-up. Also examined were associations between no return to sports and baseline patient/trauma characteristics, knee complaints and MR (magnetic resonance) findings, as well as the additive value of MR findings. Methods: Included were patients with traumatic knee complaints participating in a randomized controlled trial assessing the cost-effectiveness of an MR scan in general practice. Patients were classified as ‘no return to sports’ or ‘return to sports’ (sports on pre-injury or adapted level). Potential baseline predictors for no return to sports were assessed using logistic regression analyses. The area under the curves (AUC) was compared. Results: At six weeks and three months follow-up, 147 (59%) and 175 (74%) patients, respectively, reported return to sports. Combining patient characteristics, trauma characteristics and knee complaints predicted no return to sports with an AUC of 0.86 (95%CI: 0.81–0.90) at six weeks and of 0.82 (95%CI: 0.76–0.88) at three months follow-up. After adding MR findings, the AUC was 0.79 (95%CI: 0.71–0.87) at six weeks and 0.79 (95%CI: 0.70–0.88) at three months follow-up. Conclusion: Three out of four patients with a knee trauma in general practice reported return to sports at three months follow-up. A combination of patient/trauma characteristics and knee complaints predicted no return to sports, whereas MR findings had no additive value. Trial registration: Dutch trial registration: registration number: NTR3689. registration date: 7 November 2012.

Objective: To analyze the progression of spinal radiographic damage in patients with early axial spondyloarthritis (SpA). Methods: Axial SpA patients from the DESIR (Devenir des Spondylarthropathies Indifférenciées Récentes) cohort with 5-year spinal (cervical and lumbar) radiographs available (n = 549) were included. Two- and 5-year modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) progression and development of new syndesmophytes (net change: the number of patients with positive change minus the number of patients with negative change divided by the total number of patients) were assessed in subgroups defined at baseline according to the Assessment of SpondyloArthritis international Society axial SpA criteria and its arms, modified New York criteria (mNYC) and the presence of syndesmophytes. Results: Mean ± SD mSASSS progression was 0.2 ± 0.9 at 2 years and 0.4 ± 1.8 at 5 years. Five-year progression was higher in the imaging arm (mean ± SD 0.6 ± 2.3), magnetic resonance imaging (MRI)+/mNYC+ (mean ± SD 1.3 ± 4.0), than in the clinical arm only (mean ± SD 0.1 ± 0.7), and highest in patients with syndesmophytes (mean ± SD 2.7 ± 5.0). At 5 years, 7% of all patients had a net change of any new syndesmophyte; this value was 10% for the imaging arm (mNYC+/MRI+ with 18%), 17% for mNYC+ patients, and 42% for patients with syndesmophytes. Conclusion: Spinal radiographic progression, although limited in early axial SpA, can be captured after 2 years. Inflammation and damage in the sacroiliac joint are associated with higher radiographic progression. The presence of baseline syndesmophytes already strongly predicts the development of further structural damage early in the disease.

Background: Although infrequent, some rheumatoid arthritis (RA) patients achieve disease-modifying antirheumatic drug (DMARD)-free sustained remission. The absence of RA-specific autoantibodies, such as anticitrullinated protein antibodies (ACPA), is known to be associated with this outcome but further mechanisms underlying the chronic nature of RA are largely unknown. Magnetic resonance imaging (MRI)-detected bone marrow edema (BME), or osteitis, strongly predicts erosive progression and is associated with ACPA positivity. Therefore, we hypothesized that the presence of MRI-detected osteitis is also predictive of not achieving DMARD-free sustained remission and that the presence of osteitis mediates the association between ACPA and DMARD-free sustained remission. Methods: A 1.5 T unilateral hand and foot MRI was performed at disease presentation in 238 RA patients, evaluating BME, synovitis, and tenosynovitis (summed as MRI inflammation score). DMARD-free sustained remission, defined as the absence of clinical synovitis after DMARD cessation that persisted during the total follow-up, was assessed (median follow-up 3.8 years). Associations between the different MRI-detected inflammatory features and this outcome were studied. A mediation analysis was performed to study whether the presence of BME mediated the association between ACPA and DMARD-free sustained remission. Finally, patterns of MRI-detected inflammation with regard to DMARD-free sustained remission were studied using partial least squares (PLS) regression. Results: Forty-six (19.3%) patients achieved DMARD-free sustained remission. ACPA positivity associated independently with remission (hazard ratio (HR) 0.16, 95% confidence interval (CI) 0.06-0.39). In contrast, no associations were observed between MRI-detected BME (HR 0.99, 95% CI 0.94-1.03), or other MRI inflammatory features, and achieving DMARD-free sustained remission. Thus, the presence of BME did not mediate the association between ACPA and DMA

Background: Although infrequent, some rheumatoid arthritis (RA) patients achieve disease-modifying antirheumatic drug (DMARD)-free sustained remission. The absence of RA-specific autoantibodies, such as anticitrullinated protein antibodies (ACPA), is known to be associated with this outcome but further mechanisms underlying the chronic nature of RA are largely unknown. Magnetic resonance imaging (MRI)-detected bone marrow edema (BME), or osteitis, strongly predicts erosive progression and is associated with ACPA positivity. Therefore, we hypothesized that the presence of MRI-detected osteitis is also predictive of not achieving DMARD-free sustained remission and that the presence of osteitis mediates the association between ACPA and DMARD-free sustained remission. Methods: A 1.5 T unilateral hand and foot MRI was performed at disease presentation in 238 RA patients, evaluating BME, synovitis, and tenosynovitis (summed as MRI inflammation score). DMARD-free sustained remission, defined as the absence of clinical synovitis after DMARD cessation that persisted during the total follow-up, was assessed (median follow-up 3.8 years). Associations between the different MRI-detected inflammatory features and this outcome were studied. A mediation analysis was performed to study whether the presence of BME mediated the association between ACPA and DMARD-free sustained remission. Finally, patterns of MRI-detected inflammation with regard to DMARD-free sustained remission were studied using partial least squares (PLS) regression. Results: Forty-six (19.3%) patients achieved DMARD-free sustained remission. ACPA positivity associated independently with remission (hazard ratio (HR) 0.16, 95% confidence interval (CI) 0.06-0.39). In contrast, no associations were observed between MRI-detected BME (HR 0.99, 95% CI 0.94-1.03), or other MRI inflammatory features, and achieving DMARD-free sustained remission. Thus, the presence of BME did not mediate the association between ACPA and DMA

Objectives: Tenosynovitis (inflammation of the synovial lining of the sheath surrounding tendons) is frequently observed on MRI of early arthritis patients. Since visual assessment of tenosynovitis is a laborious task, we investigated the feasibility of automatic quantification of tenosynovitis on MRI of the wrist in a large cohort of early arthritis patients. Methods: For 563 consecutive early arthritis patients (clinically confirmed arthritis ≥ 1 joint, symptoms < 2 years), MR scans of the wrist were processed in three automatic stages. First, super-resolution reconstruction was applied to fuse coronal and axial scans into a single high-resolution three-dimensional image. Next, 10 extensor/flexor tendon regions were segmented using atlas-based segmentation and marker-based watershed. A measurement region of interest (ROI) was defined around the tendons. Finally, tenosynovitis was quantified by identifying image intensity values associated with tenosynovial inflammation using fuzzy clustering and mea

This study evaluated the value of computed tomography scans for the diagnosis of distal radioulnar joint instability. A total of 46 patients, conservatively treated for a unilateral distal radius fracture, were evaluated. Clinical instability was tested using the stress test and clunk test. A computed tomography scan of both wrists was performed in pronation and supination. Two independent observers reviewed the computed tomography scans using: the radioulnar line, subluxation ratio, epicentre and radioulnar ratio methods. Radiological distal radioulnar joint instability was assessed by comparing the measurements of the injured wrist with those of the contralateral uninjured wrists. A t

Objective: Peripheral bone mineral density (BMD) may be decreased in early rheumatoid arthritis (RA) but it is unknown whether BMD loss emerges before arthritis is clinically apparent. We aimed to study whether BMD loss occurs in patients with clinically suspect arthralgia (CSA), and whether it is associated with progression to clinical arthritis and magnetic resonance imaging (MRI)-detected subclinical inflammation.Method: Patients with CSA had arthralgia for amp;lt;1year and were at risk of progressing to RA according to their rheumatologists. At baseline, a 1.5T MRI was performed of unilateral metacarpophalangeal, wrist, and metatarsophalangeal joints, and scored on synovitis, bone marrow oedema, and tenosynovitis;. summing these features yielded the total MRI inflammation score. Digital X-ray radiogrammetry (DXR) was used to estimate BMD on two sequential conventional hand radiographs (mean interval between radiographs 4.4months). The change in BMD was studied; BMD loss was defined as a decrease of 2.5mg/cm(2)/month. Patients were followed for arthritis development for a median of 18.4months.Results: In CSA patients (n=108), change in BMD was negatively associated with age (=-0.03, p=0.007). BMD loss in CSA patients was associated with arthritis development [adjusted for age hazard ratio (HR)=6.1, 95% confidence interval (CI) 1.7 to 21.4] and was most frequently estimated in the months before clinical arthritis development. The total MRI inflammation scores were associated with the change in BMD (adjusted for age =-0.05, p=0.047). The total MRI inflammation score and BMD loss were both independently associated with arthritis development (HR=1.1, 95% CI 1.1 to 1.2, and HR=4.6, 95% CI 1.2 to 17.2, respectively).Conclusion: In CSA patients, severe BMD loss is associated with MRI-detectable subclinical inflammation and with progression to clinical arthritis., Funding Agencies|Vidi grant from the Netherlands Organisation for Scientific Research; Dutch Arthritis Foundation; EU euroTEAM

Objectives: The diagnosis of distal radioulnar joint (DRUJ) instability is clinically challenging. Computed tomography (CT) may aid in the diagnosis, but the reliability and normal variation for DRUJ translation on CT have not been established in detail. The aim of this study was to evaluate inter- and intraobserver agreement and normal ranges of CT scoring methods for determination of DRUJ translation in both posttraumatic and uninjured wrists. Materials and methods: Patients with a conservatively treated, unilateral distal radius fracture were included. CT scans of both wrists were evaluated independently, by two readers using the radioulnar line method, subluxation ratio method, epicenter method and radioulnar ratio method. The inter- and intraobserver agreement was assessed and normal values were determined based on the uninjured wrists. Results: Ninety-two wrist CTs (mean age: 56.5Â years, SD: 17.0, mean follow-up 4.2Â years, SD: 0.5) were evaluated. Interobserver agreement was best for the epicenter method [ICC = 0.73, 95Â % confidence interval (CI) 0.65–0.79]. Intraobserver agreement was almost perfect for the radioulnar line method (ICC = 0.82, 95Â % CI 0.77–0.87). Each method showed a wide normal range for normal DRUJ translation. Normal range for the epicenter method is −0.35 to −0.06 in pronation and −0.11 to 0.19 in supination. Conclusion: DRUJ translation on CT in pro- and supination can be reliably evaluated in both normal and posttraumatic wrists, however with large normal variation. The epicenter method seems the most reliable. Scanning of both wrists migh

Contains fulltext : 137063.pdf (publisher's version ) (Open Access), OBJECTIVE: To investigate if the amount of fat mass (FM) or skeletal muscle mass (SMM) is more strongly associated with knee osteoarthritis (OA), in both men and women. METHODS: The Netherlands Epidemiology of Obesity (NEO) study is a population-based cohort aged 45-65 years, including 5313 participants (53% female, median body mass index (BMI) 29.9 kg/m(2)). FM (kg), fat percentage, SMM (kg) and skeletal muscle (SM) percentage were estimated using bioelectrical impedance analysis (BIA). Clinical OA was defined following the ACR criteria. Structural OA was defined based on magnetic resonance imaging (MRI) in 1142 participants. Logistic regression analyses were used to examine the associations of all body composition measures with clinical and structural knee OA per standard deviation (SD), stratified by sex and adjusted for age and height. RESULTS: Clinical or structural OA was present in 25% and 14% of women and 12% and 13% of men, respectively. FM and fat percentage were positively associated with clinical knee OA in men and women. SMM was positively associated, while the SM percentage was negatively associated with clinical OA in both men and women. The FM/SMM ratio was positively associated with clinical OA. All determinants showed even stronger ORs for structural knee OA. In men, SMM was more strongly associated with knee OA as compared to FM whereas in women, FM was most strongly associated. CONCLUSION: Especially a high FM/SMM ratio seems to be unfavorable in knee OA. In men, SMM is most strongly associated with knee OA whereas in women FM seems to be of most importance.

Contains fulltext : 137063.pdf (publisher's version ) (Open Access), OBJECTIVE: To investigate if the amount of fat mass (FM) or skeletal muscle mass (SMM) is more strongly associated with knee osteoarthritis (OA), in both men and women. METHODS: The Netherlands Epidemiology of Obesity (NEO) study is a population-based cohort aged 45-65 years, including 5313 participants (53% female, median body mass index (BMI) 29.9 kg/m(2)). FM (kg), fat percentage, SMM (kg) and skeletal muscle (SM) percentage were estimated using bioelectrical impedance analysis (BIA). Clinical OA was defined following the ACR criteria. Structural OA was defined based on magnetic resonance imaging (MRI) in 1142 participants. Logistic regression analyses were used to examine the associations of all body composition measures with clinical and structural knee OA per standard deviation (SD), stratified by sex and adjusted for age and height. RESULTS: Clinical or structural OA was present in 25% and 14% of women and 12% and 13% of men, respectively. FM and fat percentage were positively associated with clinical knee OA in men and women. SMM was positively associated, while the SM percentage was negatively associated with clinical OA in both men and women. The FM/SMM ratio was positively associated with clinical OA. All determinants showed even stronger ORs for structural knee OA. In men, SMM was more strongly associated with knee OA as compared to FM whereas in women, FM was most strongly associated. CONCLUSION: Especially a high FM/SMM ratio seems to be unfavorable in knee OA. In men, SMM is most strongly associated with knee OA whereas in women FM seems to be of most importance.

Background: Patients with traumatic knee complaints regularly consult their general practitioner (GP). MRI might be a valuable diagnostic tool to assist GPs in making appropriate treatment decisions and reducing costs. Therefore, this study will assess the cost-effectiveness of referral to MRI by GPs compared with usual care, in patients with persistent traumatic knee complaints. Design and methods. This is a multi-centre, open-labelled randomised controlled non-inferiority trial in combination with a concurrent observational cohort study. Eligible patients (aged 18-45 years) have knee complaints due to trauma (or sudden onset) occurring in the preceding 6 months and consulting their GP. Participants are randomised to: 1) an MRI group, i.e. GP referral to MRI, or 2) a usual care group, i.e. no MRI. Primary outcomes are knee-related daily function, medical costs (healthcare use and productivity loss), and quality of life. Secondary outcomes are disability due to knee complaints, severity of knee pain, and patients' perceived recovery and satisfaction. Outcomes are measured at baseline and at 1.5, 3, 6, 9 and 12 months follow-up. Also collected are data on patient demographics, GPs' initial working diagnosis, GPs' preferred management at baseline, and MRI findings. Discussion. In the Netherlands, the additional diagnostic value and cost-effectiveness of direct access to knee MRI for patients presenting with traumatic knee complaints in general practice is unknown. Although GPs increasingly refer patients to MRI, the Dutch clinical guideline 'Traumatic knee complaints' for GPs does not recommend referral to MRI, mainly because the cost-effectiveness is still unknown. Trial registration. Dutch Trial Registration: NTR3689.

Contains fulltext : 137063.pdf (publisher's version ) (Open Access), OBJECTIVE: To investigate if the amount of fat mass (FM) or skeletal muscle mass (SMM) is more strongly associated with knee osteoarthritis (OA), in both men and women. METHODS: The Netherlands Epidemiology of Obesity (NEO) study is a population-based cohort aged 45-65 years, including 5313 participants (53% female, median body mass index (BMI) 29.9 kg/m(2)). FM (kg), fat percentage, SMM (kg) and skeletal muscle (SM) percentage were estimated using bioelectrical impedance analysis (BIA). Clinical OA was defined following the ACR criteria. Structural OA was defined based on magnetic resonance imaging (MRI) in 1142 participants. Logistic regression analyses were used to examine the associations of all body composition measures with clinical and structural knee OA per standard deviation (SD), stratified by sex and adjusted for age and height. RESULTS: Clinical or structural OA was present in 25% and 14% of women and 12% and 13% of men, respectively. FM and fat percentage were positively associated with clinical knee OA in men and women. SMM was positively associated, while the SM percentage was negatively associated with clinical OA in both men and women. The FM/SMM ratio was positively associated with clinical OA. All determinants showed even stronger ORs for structural knee OA. In men, SMM was more strongly associated with knee OA as compared to FM whereas in women, FM was most strongly associated. CONCLUSION: Especially a high FM/SMM ratio seems to be unfavorable in knee OA. In men, SMM is most strongly associated with knee OA whereas in women FM seems to be of most importance.

Contains fulltext : 137063.pdf (publisher's version ) (Open Access), OBJECTIVE: To investigate if the amount of fat mass (FM) or skeletal muscle mass (SMM) is more strongly associated with knee osteoarthritis (OA), in both men and women. METHODS: The Netherlands Epidemiology of Obesity (NEO) study is a population-based cohort aged 45-65 years, including 5313 participants (53% female, median body mass index (BMI) 29.9 kg/m(2)). FM (kg), fat percentage, SMM (kg) and skeletal muscle (SM) percentage were estimated using bioelectrical impedance analysis (BIA). Clinical OA was defined following the ACR criteria. Structural OA was defined based on magnetic resonance imaging (MRI) in 1142 participants. Logistic regression analyses were used to examine the associations of all body composition measures with clinical and structural knee OA per standard deviation (SD), stratified by sex and adjusted for age and height. RESULTS: Clinical or structural OA was present in 25% and 14% of women and 12% and 13% of men, respectively. FM and fat percentage were positively associated with clinical knee OA in men and women. SMM was positively associated, while the SM percentage was negatively associated with clinical OA in both men and women. The FM/SMM ratio was positively associated with clinical OA. All determinants showed even stronger ORs for structural knee OA. In men, SMM was more strongly associated with knee OA as compared to FM whereas in women, FM was most strongly associated. CONCLUSION: Especially a high FM/SMM ratio seems to be unfavorable in knee OA. In men, SMM is most strongly associated with knee OA whereas in women FM seems to be of most importance.

Gemeente Nijmegen, Waterschap Rivierenland en Rijkswaterstaat horen tot de eerste partijen die de basisinspanning hebben ingevuld door de totale emissie vanuit de rioolwaterzuivering en de riolering te beschouwen in plaats van alleen de emissie via de riooloverstorten. De optimalisatiestudie afval watersysteem (OAS) uit 1999 leidde tot de realisatie van een zandfilter op rwzi Nijmegen, waarmee de gemeente tot 2019 de tijd kreeg om bijvoorbeeld via afkoppelen te gaan voldoen aan de basisinspanning. In de afgelopen jaren is via de integrale OAS Nijmegen wederom een nieuwe standaard gezet door niet langer uit te gaan van een theoretische benadering, maar het feitelijk functioneren van riolering en watersysteem te toetsen aan de hand van metingen en veldonderzoek

Een versterkt broeikaseffect, een steeds intensiever gebruik van de boven- én ondergrond, koude-warmteopslag, gesleep met water vanuit het IJsselmeer gedurende droge zomermaanden: in toenemende mate loopt Drenthe met zijn huidige grondwaterbeheer tegen de grenzen van de mogelijkheden aan. Daarom ontwikkelde de Provincie Drenthe een nieuwe visie op het grondwater. Ze wil een duurzaam grondwatersysteem realiseren, dat tegelijkertijd meer dan nu mogelijkheden biedt om dat grondwater ook te gebruiken zónder daarbij de grondwatervoorraad of -kwaliteit onomkeerbaar te beïnvloeden. De strategie bestaat eruit dat de provincie de grondwatervoorraad onder het Drents Plateau vergroot en gaat benutten, bijvoorbeeld voor de drinkwatervoorziening, landbouw en natuur. In stedelijk gebied is het grondwater nodig voor economische ontwikkeling, zoals levering van koude en warmte of waterkwaliteit op maat. Op die manier wil de provincie water besparen en creëert ze mogelijk perspectieven voor levering van water buiten de provinciegrenzen: Drenthe als 'waterfabriek'

Waterkansenkaarten worden in een aantal gemeenten gemaakt om de integratie van water en ruimtelijke ordening te ondersteunen. Ze bestaan vaak uit één kaart met de belangrijkste randvoorwaarden en mogelijkheden voor die integratie. Hiermee wordt in veel gevallen geen recht gedaan aan de complexiteit van de situatie. Informatie over de ondergrond, het watersysteem en de gebiedsspecifieke hydrologische eisen ontbreken. Daarnaast worden soms uitspraken gedaan over de geschiktheid voor functies, waarbij voorbij wordt gegaan aan de vele ruimtelijke mogelijkheden om functies te realiseren en te combineren

Veel stedelijk waterprojecten die zich baseren op pretentieuze doelen blijken in de prakrijk moeilijk uitvoerbaar te zijn. In Beek-Ubbergen is het wel gelukt met veel improvisatie, intensieve gesprekken en maatwerk